Induced membrane technique versus one-stage autografting in management of atrophic nonunion of long bone in the lower limb: clinical and health burden outcomes.

OBJECTIVE: In this study, we aimed to compare the outcomes of the two-stage induced membrane technique (IMT) and one-stage autografting in the treatment of aseptic atrophic nonunion in lower limb long bones. METHODS: From January 2014 to January 2022, we reviewed all surgically treated long bone nonunion patients, including patients aged 18 years or older with atrophic nonunion, who were either treated with the two-stage induced membrane technique (IMT) or one-stage autografting. Outcome parameters interns of clinical, quality of life and healthcare burden were recorded and retrospectively analysed between the two treatment populations. The follow-up time was at least 1 year. RESULTS: In total, 103 patients who met the criteria for aseptic atrophic nonunion were enrolled. Among them, 41 (39.8%) patients were treated with two-stage IMT, and 62 (60.2%) patients were treated with one-stage autologous bone grafting. The follow-up time was 12 to 68 months, with an average of 28.4 months. The bone healing rate was comparable in both groups (IMT: 92.7% vs. one-stage grafting: 91.9%, P = 0.089) at 12 months post-operation, and the bone healing Lane-Sandhu score was superior in the IMT group (mean: 8.68 vs. 7.81, P = 0.002). Meanwhile, the SF-12 scores of subjective physical component score (PCS) (mean: 21.36 vs. 49.64, P < 0.01) and mental health component score (MCS) (mean: 24.85 vs. 46.14, P < 0.01) significantly increased in the IMT group, as well as in the one-stage grafting group, and no statistically significant difference was found within groups. However, the total hospital stays (median: 8 days vs. 14 days, P < 0.01) and direct medical healthcare costs (median: ¥30,432 vs. ¥56,327, P < 0.05) were greater in the IMT group, while the complications (nonunion 8, infection 3, material failure 2, and donor site pain 6) were not significantly different between the two groups (17.1% vs. 19.4, P = 0.770). CONCLUSION: The data indicate that two-stage method of IMT serves as an alternative method in treating atrophic nonunion; however, it may not be a preferred option, in comprehensive considering patient clinical outcomes and healthcare burden. More evidence-based research is needed to further guide clinical decision-making.

Augmentative Plating in the Treatment of Femoral Nonunion after Intramedullary Nail Fixation.

Objective: Failure of bone healing after intramedullary nailing (IMN) of a femoral diaphyseal fracture is an uncommon condition, which can cause obvious pain symptoms and seriously affect the daily life of patients. Ununion of femoral fracture requires treatment to promote successful bone union. Augmentative plating (AP) has yielded good results in treating femoral nonunion after IMN. However, there are few large cohort studies and no technical standard for this treatment. To determine (1) the proportion of individuals with femoral nonunion after IMN who achieved radiographic signs of osseous union following the additional treatment of AP and autogenous bone grafting and (2) the factors associated with the failure of this treatment. Methods: Nonunion after IMN fixation is defined as an unhealed fracture with no radiographic signs of osseous union at least six months after IMN treatment. Osseous union as bridging bone on three of four cortices with the absence of a radiolucent line. Between January 2011 and January 2022, 83 individuals diagnosed with femoral nonunion after IMN fixation underwent AP and an autogenous bone graft. Results: Seventy-six of the 83 nonunion individuals attained osseous union by 12 months. Six of 36 (16.7%) subjects with mono-cortical plates had non-union. Conversely, one of 47 subjects (2%) with bi-cortical plates had non-union. There were 18 individuals whose AP had ≤6 cortices. Five of these 18 (38.5%) individuals had non-union. Two of 65 with an AP of >6 cortices had non-union. AP with ≤ 6 cortices was a major risk factor for the likelihood of unsuccessful procedures compared to AP with > 6 cortices. Three individuals experienced incision infection at the bone graft harvest site and were treated with local wound care. Conclusions: A high proportion of individuals with femoral nonunion after IMN fixation were salvaged by AP and an autogenous bone graft. Bi-cortical plate and screw intersection of more than six cortices may increase the treatment effectiveness. Limitations: There were limitations of this study. First, it was a retrospective study over a 10-year period, and the patients were treated by different orthopedic surgeons. Second, lack of functional evaluation is another limitation of the present work. Generalizability: The technique of bi-cortical plate and screw intersection of more than six cortices is not difficult for experienced orthopedic surgeons, and no special surgical tools is required. Closing Statement: Many literature has confirmed the good effect of APP technology in treating femoral nonunion after intramedullary nail fixation, but there are still cases of failure. Our study may enable this technology to achieve better therapeutic effects.

Individualized herbal prescriptions for delayed union: A case series.

Background Bone fractures are important clinical events for both patients and professionals. Active treatment options are limited for delayed unions and for nonunions; surgery is common but not entirely risk-free. This report describes three cases of delayed union successfully treated with herbal decoction. Participants Three patients had trapezoid and 3rd metacarpal bone fractures, 2nd, and 5th metatarsal bone fractures, respectively. All three patients were diagnosed with delayed union by an independent orthopedic surgeon based on computed tomography (CT) scan/radiographic imaging and fracture duration without a healing process. Patients took herbal decoction, Jeopgol-tang, with individually added herbs based on symptom manifestations, twice daily for 56, 85 and 91 days with no additional interventions except for a splint that they had been wearing since fracture diagnosis. Outcomes Improvement of delayed union was evaluated using radiographic imaging or CT during treatment with Jeopgol-tang. Results After taking herbal medicine, callus and bony bridging were confirmed on follow-up imagings and the patients described their experience with pain reduction at an interview after recovery. Conclusions This case series suggests that the herbal decoction Jeopgol-tang warrants further investigation to establish its role as a complementary and integrative medicine treatment option for delayed unions.

A Retrospective Comparative Analysis of the Use of Implantable Bone Stimulators in Nonunions.

This study details the use of implantable bone stimulators in the setting of nonunion. A retrospective comparative analysis was used to evaluate the efficacy of implantable bone stimulators in achieving union in the setting of atrophic or oligotrophic nonunion by two fellowship-trained orthopaedic trauma surgeons. Initially, 72 patients underwent surgical intervention for nonunion. Twenty-one patients had an implantable bone stimulator placed at the time of nonunion surgery. Thirty-eight patients had a minimum of 1-year follow-up. An implantable bone stimulator was used in 13 patients and 25 patients did not have a bone stimulator. The use of implantable bone stimulators was found to be significantly associated with increased union rates (p = .042). (Journal of Surgical Orthopaedic Advances.

Carpal scaphoid non-union treatment: a retrospective trial comparing simple retrograde percutaneous screw fixation versus percutaneous screw fixation plus pulsed electromagnetic fields (Physiostim®).

BACKGROUND: The purpose of this retrospective comparative study was to assess whether a complementary treatment by pulsed electromagnetic field could increase the bone-healing rate of scaphoid non-union without SNAC (scaphoid non-union advanced collapse) treated by retrograde percutaneous screw fixation. CASE DESCRIPTION: Eighteen patients with scaphoid non-union were included in this retrospective study. The group 1 was made of nine cases (seven stage IIA and two stage IIB) of scaphoid non-union treated by retrograde percutaneous screw fixation and pulsed electromagnetic fields (Physiostim®). The group 2 was made of nine cases (six stage IIA and three stage IIB) treated by simple retrograde percutaneous screw fixation. RESULTS: With a 10-month follow-up in group 1 and a 9.5-month follow-up in group 2, there were three cases of non-union in group 1 and two cases in group 2. Regarding the type of non-union, there was one case among the stage IIB and four cases among the stage IIA. CLINICAL RELEVANCE: The results of the study did not show any interest in the use of pulsed electromagnetic field for the treatment of carpal scaphoid non-union. They should be dropped. LEVEL OF EVIDENCE: III.

Treatment of recalcitrant atrophic non-union of the humeral shaft with BMP-7, autologous bone graft and hydroxyapatite pellets.

Recalcitrant humeral non-union is a disabling condition that is extremely difficult to treat. The use of BMP-7 has been proposed to improve bone healing. This is a report of the results obtained in 12 patients with recalcitrant humeral non-union treated using stable fixation with a long locking compression plate and BMP-7, autologous bone graft and hydroxyapatite pellets applied at the non-union site. Patients had up to three surgical attempts at non-union healing prior to our treatment. The average time from the initial fracture to our surgery was 5.2 years. Average follow-up was 5.3 years. At follow-up, non-union had healed in all patients by an average of 7.3 months. All the patients were very satisfied with their final results, despite a restricted range of motion of the elbow and a moderate muscular atrophy, which was frequently observed. Our study shows that BMP-7 associated with autologous bone grafting and hydroxyapatite pellets after stable fixation is an effective adjuvant to stimulate bone healing in the treatment of recalcitrant humeral non-union.

Delayed Union of a Jones Fracture in a Patient With Rothmund-Thomson Syndrome: A Case Report and Review of the Literature.

Rothmund-Thomson syndrome is a rare autosomal recessive genodermatosis, characterized by poikiloderma, small stature, juvenile cataracts, sparse hair, skeletal abnormalities, and a predisposition to osteogenic sarcomas and skin cancers. Although numerous skeletal abnormalities have been described in patients with Rothmund-Thomson syndrome, to our knowledge, only 1 study has shown evidence of delayed fracture healing in a patient with Rothmund-Thomson syndrome. We present the case of a 13-year-old female diagnosed with Rothmund-Thomson syndrome who demonstrated delayed union of her fifth metatarsal after a Jones fracture. She was treated conservatively for 6 weeks with non-weightbearing cast immobilization and was then transitioned to a controlled ankle motion walker for an additional 4 weeks. Two months later, however, she continued to experience pain, and, on radiographic examination, the fracture remained unchanged. Therefore, with her guardian's consent, the patient elected to undergo open reduction and internal fixation of the fifth metatarsal fracture. At 8 weeks postoperatively, the patient reported a subsidence of symptoms and had returned to normal activity. With our report, we hope to increase practitioner awareness that delayed bone healing could be a possibility in patients with Rothmund-Thomson syndrome and encourage consideration of routine imaging and supplementation with calcium and vitamin D. Additionally, the present findings suggest that patients with Rothmund-Thomson syndrome could benefit from early surgical intervention, given their poor bone healing capacity and high likelihood of nonunion. Although the association between impaired bone healing and Rothmund-Thomson syndrome is rational, additional studies are needed to determine the prevalence of chronic nonunion in this patient population.

Management of the complications of traditional bone setting for upper extremity fractures: the experiences of a French Forward Surgical Team in Chad.

The practice of traditional bone setting (TBS) in sub-Saharan Africa often leads to severe complications after upper extremity fracture. The purpose of this study was to evaluate the management of these complications by a French Forward Surgical Team deployed in Chad. An observational, prospective study was conducted over a six-month period between 2010 and 2011. During this period 28 patients were included. There were 20 males and 8 females with a mean age of 30.6 years (range 5-65 years). Thirteen patients (47%) had mal-union of their fracture, nine had non-union (32%), three children (10.5%) presented gangrene and three patients (10.5%) suffered from other complications. Fifteen (54%) patients did not undergo a corrective procedure either because it was not indicated or because they declined. Only 13 (46%) patients were operated on. Twelve of these patients were reviewed with a mean follow-up of 2.4 months. All of them were satisfied with conventional treatment. The infection seemed to be under control in every septic patient. Bone union could not be evaluated in most patients because of the short follow-up. Management of TBS complications is always challenging, even in a deployed Western medical treatment facility. Surgical expectations should be low because of the severity of the sequelae and the uncertainty of patient follow-up. Prevention remains the best treatment.

Backout of the helical blade of proximal femoral nail antirotation and accompanying fracture nonunion.

This article describes a case of backout of the helical blade, a rare complication of proximal femoral nail antirotation. A 31-year-old man had sustained a trochanteric fracture of his right femur. Fracture fixation using proximal femoral nail antirotation and autologous bone grafting 7 months later were performed at another hospital. However, bony union was not obtained, and the patient's pain and limp persisted. Therefore, he presented to the current authors. A radiograph taken at presentation revealed backout of the helical blade and fracture nonunion. A radiograph taken 1 month later showed a more advanced backout of the helical blade. The authors performed exchange nailing supplemented with transplantation of peripheral blood CD34-positive cells and autologous bone grafting. The proximal femoral nail antirotation was revised to a long gamma 3 nail, and a U-lag screw was used to obtain better stability. The postoperative course was uneventful. The patient regained ambulation without pain or support at 12 weeks postoperatively. Radiographic bony union was completed 9 months postoperatively. At 1-year follow-up, he could run and stand on the previously injured leg and had returned to work. Backout of the helical blade should be considered as a possible complication of proximal femoral nail antirotation. Incomplete fixation of the helical blade is the possible reason for backout. The use of a helical blade in young patients may cause difficulty in insertion and result in incomplete fixation.

A complex injury of the distal ulnar physis: a case report and brief review of the literature.

Physeal fractures of the distal forearm are common injuries in children and adolescents. However, Salter-Harris type III and type IV fractures of the distal ulnar epiphysis are often high-energy injuries that require open reduction for restoration of anatomical alignment. These injuries are uncommon and there are few descriptions of them in the contemporary literature. Here we report the case of a 13-year-old boy with a type IV distal ulna fracture not diagnosed with standard radiography. After closed manipulation, an incompletely reduced physis was suspected on the basis of fluoroscopic imaging and comparison radiographs of the contralateral wrist. Computed tomography showed a large, displaced physeal fragment. The patient underwent open reduction and internal fixation. Thorough radiographic assessment should be conducted when there is a high suspicion for these fracture patterns. Appropriate diagnosis can lead to expedient reduction and expectant management of sequelae associated with these injuries.

Predisposing factors and outcome of treatment of non-union of long-bone fractures in Ibadan, Nigeria.

AIMS AND OBJECTIVES: This study was done to find out factors that contribute to development of Non-union of long bone fractures in this environment and the outcome of operative intervention. This is a prospective hospital based study. PATIENTS AND METHODS: All patients with Non-union of long bone fracture that presented in the hospital since January 1997 were recruited into the study. The data included causative factors, treatment given before presenting in the hospital, type of surgical procedure and result of treatment. The study was completed in December, 2005. RESULTS: 78 patients presented with 87 Non-union of long bones. A male, female ratio of 1.6:1 was encountered while 69.2 per cent of the patients were below the age 55years. Road Traffic Accident accounted for 68 fractures (78.2 per cent) while duration of injury before presentation varies from 6 months to 22 months. Atrophic non-union occurred in 60 cases (69.0 per cent) and hypertrophic non-union in 21 cases. Non-union of the femur occurred in 33 cases (37.9 per cent) humerus in 24 cases (27.6 per cent), tibia in 16 cases (18.4 per cent), radius and ulna in 14 cases (16.1 per cent). The initial treatments of the fresh fracture in the 78 patients with nonunion were by the traditional bonesetters in 51 patients (65.4 per cent) while the remaining fractures were treated by plaster of paris in hospital. Open reduction and internal fixation using plate and screws with bone grafting was the most common procedure for treating the non-union in most cases. Union was achieved in the entire patients following surgical intervention. CONCLUSION: Important factor that appears to contribute to non-union of long bone in this environment is soft tissue interposition between the fracture ends of the bone, which is found in all fractures with more than one diameter displacement. Another factor is interference with periosteal blood supply from disruption of soft tissue envelope as a result of high energy injuries which is also responsible for the displacements that were observed in these fractures. The treatment by traditional bone setters which entails daily massage of the fracture creating a macro movement at the fracture site is also an important contributing factor.

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing.

INTRODUCTION: Treatment of lower extremity segmental bone loss is difficult. Masquelet et al. proposed a two-stage technique: first, debridement and filling of bone loss with an acrylic spacer; second, bone reconstruction by filling with cancellous bone in the space left free (following cement removal) inside the so-called self-induced periosteal membrane. In the originally described technique, the fracture site is stabilized by an external fixator, which remains in place throughout the bone healing process, i.e., often longer than 9 months with all the known disadvantages of this type of assembly. Following the principle of two-stage reconstruction, we modified the technique by reconstructing around an intramedullary-locking nail placed in the first stage. HYPOTHESIS: This technique prevents the mechanical complications related to external fixator use and provides faster resumption of weight-bearing. PATIENTS AND METHODS: Twelve patients were operated for segmental tibial bone loss greater than 6cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis (seven cases). All the patients were operated on in an emergency setting and the first stage was performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocutaneous flap (two patients) was necessary during this first step to cover the site and provide good conditions for secondary bone growth. The follow-up was 39.5 months (range, 12-94 months). RESULTS: Complete weight-bearing was resumed at a mean 4 months. After the second step, all the patients except one had apparently healed (complete weight-bearing with no pain). Five septic complications occurred after the second step, in one case leading to reconstruction failure. Four other patients had infectious complications successfully treated (as of the last follow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in two other cases, with no graft loss. DISCUSSION: The use of the intramedullary nail facilitates the Masquelet technique by allowing the patient to resume weight-bearing more quickly and avoiding secondary fractures. However, the risk of sepsis remains high but can be controlled without compromising the final bone union in four cases out of five. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Management of a mandibular fracture accompanying a gunshot wound.

Gunshot injuries of the mandible can result in high rates of complications, especially in cases of bone loss. A fractured mandible accompanying a gunshot wound almost always has an external wound; the fracture is always compound and comminuted. Sometimes management of these injuries may require multiple surgical interventions. In this clinical report, treatment of a patient, who had a mandibular fracture due to a gunshot wound, is presented.A 52-year-old man with a mandibular fracture in the right mandibular body accompanying a gunshot wound was operated on. Owing to a nonunion, a second surgery was performed using reconstruction plates after hyperbaric oxygen treatment. Healing was uneventful after the second surgical intervention.

Do successful surgical results after operative treatment of long-bone nonunions correlate with outcomes?

UNLABELLED: There has been increased emphasis on validated, patient-reported functional outcomes after orthopaedic interventions for various conditions. The few reports on these types of outcomes after treatment of fracture nonunions are limited to specific anatomic sites, limited by small numbers, and retrospective. To determine whether successful healing of established long-bone nonunions resulted in improved functional outcomes and reduction in patient-reported pain scores, we prospectively followed 80 patients. These patients had a mean of 1.4 surgical procedures before enrollment and a mean of 18 months had elapsed from previous surgery until enrollment. Baseline data and functional scores were obtained before intervention. Seventeen of the 80 patients (21%) had positive intraoperative cultures. At a mean of 18.7 months (range, 12-36 months), 72 (90%) nonunions had healed. Patients with healed nonunions scored better on the Short Musculoskeletal Functional Assessment. Pain scores among all patients improved compared with baseline, but to a greater degree in patients who achieved healing by final followup. Our data suggest improvement in pain scores is seen in all patients after surgery, whereas successful internal fixation leads to improved function. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Electric stimulation and hyperbaric oxygen therapy in the treatment of nonunions.

Up to 10% of the fractures occurring annually in the U.S. end up in non-union or delayed union. Classical treatment with osteosynthesis and bone grafting is not always successful. Alternatives in treatment have long ago been considered. This article presents current concepts in treatment with electrical stimulation and hyperbaric oxygen, the mechanisms of action, experimental and clinical evidence of their application.

Demineralized bone matrix graft: a scientific and clinical case study assessment.

Osteoinductive demineralized bone matrix results from bone demineralization and is attributed to matrix-associated bone morphogenetic proteins. The osteoinductive potential can vary with donor. Many bioassay methods are available to screen donors, each with its own interpretation, so performance of more than one may be of value. Furthermore, little is known about the relationship between bioassay results and clinical outcomes. A study designed to meaningfully explore these issues would require assay of a large number of donors as well as clinical utilization in a large patient population. A preliminary study was undertaken to gain initial perspective. Using demineralized bone matrix derived from one 33-year-old female donor, 2 methods of bioassay and a clinical case study were performed. The levels of bone morphogenetic proteins 2, 4, and 7 in lyophilized demineralized bone matrix powder were measured (19.65 +/- 0.30 ng/g, 2.49 +/- 0.19 ng/g, and 82.03 +/- 6.89 ng/g, respectively). Also, putty (Osteostim DBM Putty), prepared from powder, was intramuscularly implanted in athymic rats and de novo bone formation quantified (6.7% +/- 3.5% new bone formation with 49% +/- 17% of the implant area associated with new bone formation). The putty, in conjunction with internal fixation, was used in the revision of a medial malleolar nonunion of an obese, 76-year-old woman. Radiographic union with excellent graft incorporation was achieved by 12 weeks postoperatively, with maintenance of an acceptable clinical result during the 14-month follow-up period. These results are interpreted in the broader context of demineralized bone grafting, in general, and an outline for further study is presented.

Callusmassage. A new treatment modality for non-unions of the irradiated mandible.

Recent reports on orthopaedic surgery focus on mechanical stimulation of the regenerate during distraction therapy of non-unions in long-bone-surgery. In the field of maxillofacial surgery, callus stimulating techniques are rarely reported. The case of a 65-year-old man with a radiogenic mandibular non-union after ablative tumour therapy and pre-operative radiation therapy presented with a non-union. Vertical distraction in combination with subsequent repeated, stepwise compression and distraction (=massage) had a positive effect on the consolidation of the regenerate.

Treatment of nonunions and osseous defects with bone graft and calcium sulfate.

The treatment of long bone nonunions and fractures with osseous defects is challenging. The results of 26 patients with either a persistent long bone nonunion or an osseous defect after an open fracture were reviewed. Each patient was treated with debridement of devitalized tissue, open reduction and internal fixation, and bone grafting using a mixture of autogenous iliac crest bone graft and medical grade calcium sulfate. The current study evaluated the union rate and associated complications for treatment of these injuries using this protocol. Each nonunion was confirmed intraoperatively, and healing was determined clinically by the patients' return to full activities without pain and radiographically by the presence of bridging trabeculae. Complications included persistent nonunion (four patients), wound drainage (five patients), wound drainage and cellulitis (one patient) and cellulitis alone (one patient). Using this treatment protocol, 22 patients (85%) achieved healing after one surgery and an additional two patients (92%) achieved healing after a second surgery. Medical grade calcium sulfate increases the volume of graft material, facilitates bone formation, and is safe in the treatment of nonunions and fractures with osseous defects.

The effect of allomatrix injectable putty on the outcome of long bone applications.

Long bone defects due to nonunion or surgical excision of benign bone tumors result in areas that require rapid regeneration of local bone. This clinical and radiographic article details the results of a commercially prepared allograft demineralized bone matrix in patients with long bone voids or gaps. Of the 76 patients included for study, 41 (54%) patients were undergoing surgical intervention for removal of benign tumors or space-occupying lesions and 35 (46%) patients had long bone nonunions. AlloMatrix Injectable Putty (Wright Medical Technology, Inc, Arlington, Tenn) was used alone in 74 (97%) patients and in combination with bone marrow aspirate in two (3%) patients with tibial nonunion. Adjunctive strut allografts were used in three patients with humeral nonunion. The average time to follow-up for the combined population was 7 months (nonunion group 6 months; benign tumor group 7 months). At the most recent follow-up, radiographic evidence of the average percent of bone healing was 85.1% for the nonunion patient group and 93% for the benign tumor patient group. From this study, AlloMatrix Injectable Putty used as a bone void filler in long bone nonunions and benign tumors shows results equal to those historically reported for autograft and other materials.

The treatment of infected tibial nonunion with aggressive debridement and internal bone transport.

Tibial nonunions are a challenging situation for both healing and reconstruction when infection is added. In this retrospective study, we discuss the cases in which we had managed to obtain union by aggressive debridement, circular external fixature, and internal bone transport. Fourteen cases had been treated between January 1995 and December 2000 in the Orthopedics and Traumatology Department of the Gulhane Military Medical Academy. The mean follow-up period was 33.2 (12-60 months) months. The mean length of defects was 4.4 (2.5-8 cm) cm. These defects were repaired by corticotomy and by internal bone transport only. Pseudoarthrosis and union of corticotomy sites occurred in a mean period of 6.8 (4.5-15) months. In two of our patients, reinfection occurred, and hyperbaric oxygen therapy was applied to them. We concluded that in tibial infected nonunions, satisfactory union and control of infection are possible by radical debridement, stable fixation by circular external fixature, osteotomy and callus distraction, antibiotic therapy, and hyperbaric oxygen therapy whenever needed.